+ DSM-5 Making the Transition to the New Manual

+

DSM-5: Making the Transition to the New Manual Dr. Christine Chasek LIMHP, LADC

University of Nebraska at Kearney Burke and Associates, PC

+ Introduction

+ Agenda for the Day

n DSM 5 Overview and Basics

n Disorders and Criteria Changes by Category

n Lunch! On-site

n Continue Disorders and Criteria

n Implications and Billing

n Questions/Wrap up/Evaluations

+ DSM-5: The How To Manual

n Purpose of the DSM-5 – Stimulate new clinical perspectives; align closer to the ICD system

n What to do when you get your new DSM-5 1. Cry – because of the money you had to spend and the hours you will spend learning it and re-learning what has

become second nature to you! 2. Read the manual (Yes I did say read it!) In this order:

Section I: DSM 5 Basics Highlights of Changes from DSM-IV-TR to DSM-5 Section II: Diagnostic Criteria and Codes

+ DSM- The “Evolution of our Profession” Manual

+ Basic Changes in the DSM-5

n Moved from a categorical model to scientifically-validated measures, rating scales, and the impact of culture

n Chapters are restructured based on the disorders’ relatedness to one another as well as symptom characteristics

n 15 new Diagnoses were added; some diagnoses were reclassified or removed; some diagnostic criteria were clarified

n Axial system was removed!

n The way the diagnosis is recorded has changed significantly

+ DSM-5 Basics n  New definition of “mental disorder” focused on clinically significant

disturbances, developmental processes, culturally approved responses, and social deviant behavior (pg 20).

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. DSM-5

+ DSM-5 Basics n  A Dimensional Approach to Diagnosis: The DSM-5 is intended to encourage

client conceptualization from a physical, psychological, cognitive, and cultural viewpoint n  Move away from limited categorical diagnosis to a more holistic view of

clients that takes into consideration developmental and lifestyle issues, cultural issues, and gender differences

n  The disorders are organized into a framework beginning with those that occur in early life, followed by disorders that occur in adolescence and young adulthood, and ends with diagnosis more relevant to adulthood and later life

n  Clustering of disorders in a framework of “internalizing” and “externalizing” n  Internalizing- disorders with prominent anxiety, depressive and somatic

symptoms n  Externalizing-disorders with prominent impulsive, disruptive conduct, and

substance use symptoms

+ DSM-5 Basics þ n  Not meant to merely be a “check off” of clinical criteria; must

complete a full clinical history taking into account the “new” definition of mental disorders. The diagnosis should also should have clinical utility determining prognosis, treatment planning, and treatment outcomes.

n  Expanded elements of a diagnosis: n  Diagnostic criteria are the guidelines for making a diagnosis n  Subtypes and specifiers are used for increased specificity when

the full criteria are met when applicable n  Specific criteria for defining disorder severity (mild, moderate,

severe etc.), descriptive features (in a controlled environment, etc.), and course (remission, partial remission, etc. ) are used when applicable

+ DSM-5 Basics n  Dimensional Assessment versus a Multiaxial Assessment

n  The multiaxial system is gone in the DSM-5. It is replaced by a nonaxial documentation of diagnosis (formerly Axis I, II, and III) with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V). This is the dimensional assessment in action!

n  Axis I,II, and III are combined

n  Axis IV is now replaced with ICD 9 V codes (Z codes-in the ICD-10).

n  Many of the previous Axis IV issues are listed in Other Conditions That May Be a Focus of Clinical Attention (pgs 715-727)

n  Axis V will be replaced with the WHODAS scales; currently it is optional and not required to be recorded in the diagnosis (pg 745) however this will likely change soon.

+ DSM-5 Diagnosis Vs. Billing Codes n  The DSM-5 is a set of diagnostic criteria that is used to select the appropriate

ICD-9 / ICD-10 codes for billing.

n  The DSM-5 was written to crosswalk with both the ICD-9 and 10 codes.

Ex: 296.21 (F32.0) Major Depressive Disorder, Single Episode, Mild

ICD-9 Code ICD-10 Code

The current DSM 5 codes are compatible with the ICD-9; the ICD-10 codes are added in parenthesis

n  Sometimes different disorders / subtypes share the same diagnostic code. This is not an error! It is because the DSM-5 is designed to match the ICD-9 (10) codes and sometimes there isn’t a separate code for diagnoses.

EX: 300.3 (F42) Obsessive-Compulsive Disorder 300.3 (F42) Hoarding Disorder

+ Example “NEW” DSM-5 Diagnosis

n  V62.21 Problem Related to Current Military Deployment Status, 300.4 Persistent Depression Disorder (Dysthymia), With anxious distress, In partial remission, early onset, With pure dysthymic syndrome, Moderate, 278.00 Overweight or Obesity, WHODAS: 63

n  312.39 Trichotillomania (Hair-Pulling Disorder), 305.70 Mild Methamphetamine Disorder, V62.4 Social Exclusion or Rejection, WHODAS: 70

n  What are your first reactions?

n  What makes this so different and why?

+ DSM-5 Basics n  Principal Diagnosis

n  When more than one diagnosis is given, the principal diagnosis should be identified; the principal diagnosis should be the primary focus of treatment.

n  The Principal diagnosis is listed first followed by the others in order of focus of attention and treatment.

n  Provisional Diagnosis n  The specifier “provisional” can be used when there is a strong presumption

that the full criteria for the disorder will be met but not enough information is available to make a firm diagnosis, also used when the duration of the illness is an issue (criteria met for 5 months when 6 months is the criteria for duration);

n  Write “Provisional” following the wording of the diagnosis when this is used

+ DSM-5 Basics n  To enhance diagnostic specificity, the previous NOS designation in DSM IV-

TR has been replaced with:

n  Other Specified Disorder- used to record the specific reasons the client does not meet the criteria for any specific category within the diagnosis class; can use the DSM wording or you own after the Other Specified

Ex: 311 Other Specified Depressive Disorder, depressive episode with insufficient symptoms

n  Unspecified Disorder – used to record a diagnosis that doesn’t meet the specific criteria for the diagnosis but the clinician does not choose to specify the specific reason

Ex: 311 Unspecified Depressive Disorder

n  These two choices take into account client presentations that do not fit exactly into the diagnosis boundaries of each of the disorders.

+ DSM-5 Chapters and Sequence n  1. Neurodevelopmental Disorders

n  2. Schizophrenia Spectrum and Other Psychotic Disorders

n  3. Bipolar and Related Disorders

n  4. Depressive Disorders

n  5. Anxiety Disorders

n  6. Obsessive-Compulsive and Related Disorders

n  7. Trauma- and Stessor-Related Disorders

n  8. Dissociative Disorders

n  9. Somatic Symptom Disorders

n  10. Feeding and Eating Disorders

n  11. Elimination Disorders

n  12. Sleep-Wake Disorders

n  13. Sexual Dysfunction

n  14. Gender Dysphoria

n  15. Disruptive, Impulse Control and Conduct Disorder

n  16. Substance-Related and Addictive Disorders

n  17. Neurocognitive Disorders

n  18. Personality Disorders

n  19. Paraphilic Disorders

n  20. Other Disorders

+ Highlights of Major Changes in Diagnostic Criteria

n  Mood Disorders are separated into Depressive Disorders and Bipolar Disorders

n  Anxiety Disorders are broke out into Anxiety, OCD, Trauma

n  Neurocognitive Disorder replaces Dementia

n  Gender Identity Disorder is out of the Sexual Dysfunctions chapter and is now Gender Dsyphoria

n  Mental Retardation is gone- Intellectual Disability added

n  Autism Spectrum Disorder –combines all previous disorders

n  Several changes in Diagnostic Criteria for ADHD have been made

n  Obsessive-Compulsive and Related Disorders (New) contains Hoarding Disorder

n  Depressive Disorders: n  Disruptive Mood Dysregulation disorder for children up to 18 years n  Dysthymia changed to Persistent Depressive Disorder

+ Good Websites to Keep your Eye on for DSM-5 Information

n DSM 5 Home Page

n Magellan DSM 5 Information